Covered Entity Details

CAH281342-01 SAINT MARY'S HOSPITAL d/b/a CHI Health St Mary's (Active) - information as of 6/7/2025 6:08:42 AM

Main Details

Name

SAINT MARY'S HOSPITAL d/b/a CHI Health St Mary's

Subdivision Name

Nebraska City Medical Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH281342-01

Medicare Provider Number

281342

Outpatient Facility Provider Number

283859

Additional Details

Current Program Status

Active

Registration Date

4/15/2013

Participating Start Date

7/1/2013

Participating Approval Date

5/1/2013

Last Recertification Date

8/21/2024

Contacts

Authorizing Official

CHI Health St. Mary's
Daniel J DeFreece, Interim President
(402) 873-3321

Primary Contact

CommonSpirit Health - Central Region
Mitchell Schultz, RPh, 340b Regional Manager
(701) 928-0620

Addresses

Street Address

1301 Grundman BLVD
Suite A
Nebraska City, NE 68410

Billing Address

CHI Health St. Mary's
PO Box 70
Nebraska City, NE 68410

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
NE	100263265-01,100263120-00,100263265-00,196127,649228001	1528016995,1851737316
IA	092349	1528016995,1851737316

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH281342-01	Child	CAH	SAINT MARY'S HOSPITAL d/b/a CHI Health St Mary's	Nebraska City Medical Clinic	1301 Grundman BLVD	Nebraska City	NE	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/16/2023 5:04:17 PM	8/21/2024 8:35:13 AM	8/21/2024 8:35 AM
Contacts	Primary Contact	Update	Profile Change Request	Schultz, Mitchell RPh, 340b Division Manager CommonSpirit Health - Midwest Division 7019280620	Schultz, Mitchell RPh, 340b Regional Manager CommonSpirit Health - Central Region 7019280620	8/6/2024 1:57 PM
Contacts	Primary Contact	Update	Profile Change Request	Schultz, Mitchell RPh CommonSpirit Health - Midwest Division 7019280620	Schultz, Mitchell RPh, 340b Division Manager CommonSpirit Health - Midwest Division 7019280620	9/27/2023 5:22 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 3:16:17 PM	8/16/2023 5:04:17 PM	8/16/2023 5:04 PM
Details	Last Recertification Date	Update	Recertification	8/18/2021 3:41:38 PM	8/29/2022 3:16:17 PM	8/29/2022 3:16 PM
Contacts	Primary Contact	Update	Profile Change Request	Schultz, Mitchell RPh CHI St. Alexius Health Carrington 7019280620	Schultz, Mitchell RPh CommonSpirit Health - Midwest Division 7019280620	3/10/2022 3:00 PM
Contacts	Primary Contact	Update	Group Change Request	Warren, Amanda Darlene Pharmacy Supervisor CHI Health St. Mary's 4028738938	Schultz, Mitchell RPh CHI St. Alexius Health Carrington 7019280620	2/11/2022 7:25 AM
Details	Last Recertification Date	Update	Recertification	8/27/2020 7:50:11 AM	8/18/2021 3:41:38 PM	8/18/2021 3:41 PM
Addresses	Billing Address	Insert	Change Request		CHI Health St. Mary's PO Box 70 Nebraska City, NE 68410	10/22/2020 2:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100263265-01	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100263120-00	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100263265-00	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		196127	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		649228001	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		092349	10/2/2020 3:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	10/2/2020 3:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1528016995	10/2/2020 3:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	10/2/2020 3:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851737316	10/2/2020 3:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	10/2/2020 3:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1528016995	10/2/2020 3:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	10/2/2020 3:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851737316	10/2/2020 3:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	10/2/2020 3:46 PM
Contacts	Primary Contact	Update	Recertification	BECCARD, JOAN PHARMACY DIRECTOR CHI Health St. Mary's 4028738938	Warren, Amanda Darlene Pharmacy Supervisor CHI Health St. Mary's 4028738938	8/27/2020 7:50 AM
Details	Last Recertification Date	Update	Recertification	8/21/2019 11:46:08 AM	8/27/2020 7:50:11 AM	8/27/2020 7:50 AM
Details	Last Recertification Date	Update	Recertification	9/4/2018 2:20:13 PM	8/21/2019 11:46:08 AM	8/21/2019 11:46 AM
Details	Entity Name	Update	Recertification	ST. MARY COMMUNITY HOSPITAL d/b/a CHI Health St Mary's	SAINT MARY'S HOSPITAL d/b/a CHI Health St Mary's	9/5/2018 9:02 AM
Details	Last Recertification Date	Update	Recertification	11/22/2017 12:07:23 PM	9/4/2018 2:20:13 PM	9/4/2018 2:20 PM
Contacts	Authorizing Official	Update	Change Request	Kelly, Daniel J. President CHI Health St. Mary's 4028738901	DeFreece, Daniel J Interim President CHI Health St. Mary's 4028733321	4/27/2018 8:19 AM
Details	Last Recertification Date	Update	Recertification	9/5/2016 12:00:00 AM	11/22/2017 12:07:23 PM	11/22/2017 12:07 PM
Contacts	Authorizing Official	Update		Kelly, Daniel J. President 4028738901	Kelly, Daniel J. President CHI Health St. Mary's 4028738901	10/16/2017 12:52 PM
Contacts	Primary Contact	Update		BECCARD, JOAN PHARMACY DIRECTOR 4028738938	BECCARD, JOAN PHARMACY DIRECTOR CHI Health St. Mary's 4028738938	9/30/2017 1:55 PM
Addresses	Main Address	Insert			1301 Grundman BLVD Suite A Nebraska City, NE 68410	9/5/2016 9:02 AM
Contacts	Primary Contact	Insert			BECCARD, JOAN PHARMACY DIRECTOR 4028738938	9/5/2016 9:02 AM
Contacts	Signed By	Insert			CLOSNER, SHAWN V.P OF FINANCE 4028738951	9/5/2016 9:02 AM
Contacts	Authorizing Official	Insert			Kelly, Daniel J. President 4028738901	9/5/2016 9:02 AM
Details	Last Recertification Date	Update		9/2/2015 12:00:00 AM	9/5/2016 12:00:00 AM	9/5/2016 9:02 AM
Details	Last Recertification Date	Update		9/5/2014 12:00:00 AM	9/2/2015 12:00:00 AM	9/2/2015 10:39 AM
Details	Entity Name	Update		ST. MARY COMMUNITY HOSPITAL	ST. MARY COMMUNITY HOSPITAL d/b/a CHI Health St Mary's	11/28/2014 2:09 PM
Details	Last Recertification Date	Update		9/6/2013 12:00:00 AM	9/5/2014 12:00:00 AM	9/5/2014 12:08 PM
Details	Last Recertification Date	Update		9/6/2013 3:21:49 PM	9/6/2013 12:00:00 AM	12/11/2013 8:00 AM
Details	Last Recertification Date	Update			9/6/2013 3:21:49 PM	9/6/2013 3:21 PM
Details	340B ID	Update		ISDMCAH281342-01	CAH281342-01	5/1/2013 5:51 PM
Dates	Participating Approval Date	Update			5/1/2013 12:00:00 AM	5/1/2013 5:51 PM
Details	State	Update		Pending	Active	5/1/2013 5:51 PM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	5/1/2013 5:51 PM
Details	340B ID	Update		DM-041613D	ISDMCAH281342-01	4/17/2013 11:26 AM
Details	340B ID	Update		DM041513C	DM-041613D	4/16/2013 2:24 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DM041513C	4/15/2013 8:36 PM
Details	Last Recertification Date	Insert				4/15/2013 4:45 PM
Details	Grant Number	Insert				4/15/2013 4:45 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/15/2013 4:45 PM
Details	Is Authorizing Official EHB Data	Insert				4/15/2013 4:45 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/15/2013 4:45 PM
Details	Medicare Provider Number	Insert			281342	4/15/2013 4:45 PM
Details	Entity Name	Insert			ST. MARY COMMUNITY HOSPITAL	4/15/2013 4:45 PM
Details	Program Code	Insert			CAH	4/15/2013 4:45 PM
Details	Entity Subname	Insert			Nebraska City Medical Clinic	4/15/2013 4:45 PM
Dates	Participating Approval Date	Insert				4/15/2013 4:45 PM
Details	State	Insert			Pending	4/15/2013 4:45 PM
Dates	Registration Date	Insert			4/15/2013 12:00:00 AM	4/15/2013 4:45 PM
Dates	Signed By Date	Insert			4/15/2013 12:00:00 AM	4/15/2013 4:45 PM
Dates	Start Date	Insert				4/15/2013 4:45 PM
Terminations	Termination Comments	Insert				4/15/2013 4:45 PM
Terminations	Termination Date	Insert				4/15/2013 4:45 PM
Terminations	Termination Effective Date	Insert				4/15/2013 4:45 PM
Terminations	Termination Reason	Insert				4/15/2013 4:45 PM